ELKO, Nev. — When Ruby B. Sutton found out she was pregnant in late 2021, it was hard to envision how her full-time job would fit with having a newborn at home. She faced a three-hour round-trip commute to the mine site where she worked as an environmental engineer, 12-plus-hour workdays, expensive child care, and her desire to be present with her newborn.

Sutton, 32, said the minimal paid maternity leave that her employer offered didn't seem like enough time for her body to heal from giving birth or to bond with her firstborn. Those concerns were magnified when she needed an emergency cesarean section.

"I'm a very career-driven person," Sutton said. "It was really difficult to make that decision."

Sutton quit her job because she felt even additional unpaid time off wouldn't be enough. She also knew child care following maternity leave would cost a substantial portion of her salary if she returned to work.

Tens of millions of American workers face similar decisions when they need to care for themselves, a family member, or a baby. Wild variations in paid leave regulations from state to state and locally mean those choices can be further complicated by financial factors.

And workers in rural areas face even more challenges than those in cities, including greater distances to hospitals and fewer medical providers, exacerbating health and income disparities. Companies in rural areas may be less likely to voluntarily offer the benefit because they tend to be smaller and there are fewer employers for workers to choose from.

While a growing number of states, cities, and counties have passed laws ensuring paid sick leave or general paid time off in recent years, most states where more than 20% of the population is rural haven't, leaving workers vulnerable. Vermont and New Mexico are the only states with a sizable rural population that have passed laws requiring some form of paid sick leave.

Experts say the gaps in paid leave requirements mean workers in rural areas often struggle to care for themselves or loved ones while making ends meet.

"The problem is, because it's a small percentage of the population, it's often forgotten," said Anne Lofaso, a professor of law at West Virginia University.

The COVID pandemic steered attention toward paid leave policies as millions of people contracted the virus and needed to quarantine for five to 10 days to avoid infecting co-workers. The 2020 Families First Coronavirus Response Act temporarily required employers with fewer than 500 employees and all public employers to give workers a minimum of two weeks of paid sick leave, but that requirement expired at the end of 2020.

The expiration left some workers to rely on the Family and Medical Leave Act of 1993, which requires companies with 50 or more employees to provide them with up to 12 weeks of unpaid time off to care for themselves or family members. But many workers can't afford to go that long without pay.

By March 2022, 77% of workers at private companies had paid sick leave through their employers, according to the Bureau of Labor Statistics — a small increase from 2019, when 73% of workers in private industry had it. But workers in certain industries — like construction, farming, forestry, and extraction — part-time workers, and lower-wage earners are less likely to have paid sick leave.

"Paid leave is presented as a high-cost item," said Kate Bronfenbrenner, director of labor education research at the School of Industrial and Labor Relations at Cornell University.

But without it, people who feel pressure to go to work let health conditions fester and deteriorate. And, of course, infectious workers who return too early unnecessarily expose others in the workplace.

Advocates say a stronger federal policy guaranteeing and protecting paid sick and family leave would mean workers wouldn't have to choose between pushing through illness at work or losing income or jobs.

A recent report by New America, a left-leaning think tank, argues that creating policy to ensure paid leave could boost employment numbers; reduce economic, gender, and racial disparities; and generally lift up local communities.

Support for paid sick and family leave is popular among rural Americans, according to the National Partnership for Women & Families, which found in 2020 polling that 80% of rural voters supported a permanent paid family and medical leave program, allowing people to take time off from work to care for children or other family members.

But lawmakers have been divided on creating a national policy, with opponents worrying that requiring paid leave would be too big a financial burden for small or struggling businesses.

In 2006, voters in San Francisco approved the Paid Sick Leave Ordinance, making it the first U.S. city to mandate paid sick leave. Since then, 14 states, the District of Columbia, and 20 other cities or counties have done so. Two other states, Nevada and Maine, have adopted general paid time off laws that provide time that can be used for illness.

Federal workers are offered 12 weeks of paid parental leave in the Federal Employee Paid Leave Act, adopted in October 2020. It covers more than 2 million civilian workers employed by the U.S. government, though the law must be reapproved each fiscal year and employees are not eligible until they've completed one year of service.

The patchwork of laws nationwide leaves workers in several mostly rural states — places like Montana, South Dakota, and West Virginia where more than 40% of residents live outside cities — without mandated paid sick and family leave.

Sutton said she "would have definitely loved" to stay at her job if she could've taken a longer paid maternity leave. She said she wants to return to work, but the future is unclear. She has more things to consider, like whether she and her husband want more children and when she might feel healthy enough to try for a second baby after last summer's C-section.

Sutton recalled a friend she worked with at a gold mine years ago who left the job a few months after having a baby. "And I understand now all the things she was telling me at that time. ... She was like, 'I can't do this,' you know?"

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.